Payer Enrollment

Before submitting additional payer requests, please review the following:

  • The Third Party Claims module is required to electronically submit commercial claims.
  • The RelayHealth Payer List is available to review prior to submitting an Additional Payer Request.
    • View the RelayHealth Payer List here
    • Payers may still be requested if they are not represented on the payer list.
    • If RelayHealth does not have connectivity to the requested payer, an option to request connectivity will be offered.
  • Additional Payer Requests are processed in the order received.
  • Set up timeframes vary by payer.
  • Incomplete and inaccurate requests may cause a delay in setup. To prevent unnecessary delays, please provide as much information in the request as possible.

Facility Name: *

MatrixCare Client ID: *

ePREMIS CID:

Facility NPI: *

Facility Tax ID: *

Is this tax ID shared with other facilities, hospitals or care-settings?: *

Enrollment Contact: *

Enrollment Contact Title: *

Enrollment Contact Email: *

Enrollment Contact Phone: *

Enrollment Contact Fax: *

Authorized Signer’s Name: *

Authorized Signer’s Title: *

Authorized Signer's Email: *

Authorized Signer Phone: *

Authorized Signer Fax: *

Claims Management Payer Name: *

LOB:

NEIC/Payer ID:

Provider ID/PTAN: *

Form Type:

State Specific Managed Medicaid Program: